Introducción
INTRODUCTION Systemic lupus erythematosus (SLE) is an autoimmune disease with multisystem involvement. Lupus nephritis (LN) is a type of glomerulonephritis caused by the deposition of immune complexes. Kidney involvement is a major determinant for individualized immunosuppressive. Refractory LN causes kidney disease progression and increases the risk of loss of renal function.

Caso
CASE PRESENTATION A 17-year-old woman with SLE and renal involvement. At 8 years old, she diagnosed with diffuse LN, had conventional treatment with cumulative cyclophosphamide dose greater than 10 g. Rituximab (RTX) has been proposed as an alternative treatment for refractory LN (cumulative dose: 2.25g) with partial response, achieving partial remission. This patient with refractory LN developed atypical pneumonia and cellulitis while using RTX therapy. On admission, the patient had abnormal renal function, renal histopathology indicated mixed proliferative and membranous lupus nephritis with active and chronic lesions, increased damage accrual, sequential therapies of various combinations of a multitarget regimen and RTX. Due to poor adherence led to refractoriness until the need for renal replacement therapy.

Comentario
Immunosuppressive treatment is constantly evolving, and despite the recommendations on the use and tissue accumulation of these medications in medical practice is exceeded by the clinical behavior of the pathology. Unfortunately, a subset of refractory ln patients fails to respond to immunosuppression remain and are a management challenge with a high risk of a poor outcome, lasting less time has been recently introduced in alternative and non-inferiority treatments.

Conclusión
Lupus nephritis is a devastating complication that requires early diagnosis and aggressive and highly individualised management to preserve long-term kidney function. However, the underlying pathogenesis in refractory LN.